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Written by Curtis Shew
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Tuesday, 29 June 2010 |
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2011 and 2012 Medical Benefit Changes for Active Employees
When you get your open enrollment package for 2011 and 2012 open and read it carefully there will be changes in it. DO NOT GET CAUGHT BY SUPRPRSE. There will be a premium of $10 for Individual coverage and $25 for Family coverage for in 2011. In 2012 the premiums will be $35 for Individual and $75 for Family. These premiums will be for the PPO and POS plans. For Bapco and Utility’s the premiums will be $35 for Individual and $75 for Family in 2011 and 2012. No premiums were anticipated for the HMO plans or EPO plans, but CHECK YOUR OPEN ENROLLMENT PACKAGES. No Change in the Active Part-time monthly contributions. In 2011 and 2012 the Spousal Carve-out premium will be eliminated. Employees will be allowed to cover his/her spouse under the family premium. Preventive Care Preventive Care will be covered at 100%, (No copays, no deductibles, no coinsurance payments) as long as you use network providers. Preventive care services are generally linked to routine wellness exams, while nonpreventive services are considered treatment or diagnosis for an existing illness, injury or condition. Examples of preventive care: Annual routine physicals Pap smears Cholesterol screenings Mammograms Colonoscopies Some immunizations This isn’t a comprehensive list. Check with your medical insurance carrier for what they consider Preventive Care. Deductibles and Out of Pocket Maximums An In-Network deductible of $350 for Individual and $ 700 for Family will be in effect for the life of this agreement There will be a Co-insurance (excluding preventive care) of 10% for In-Network and 40% for Out of Network Co-insurance is the percentage of charges you pay for covered services, in addition to any applicable deductible. Out of Pocket Maximums: In Network $1000 Individual/ $3000 Family Out of Network $3000 Individual/ $6000 Family Individual basis for deductibles and out of pocket maximums—the family out of pocket maximum is met once any combination of covered persons’ coinsurance meets the family out of pocket maximum amount.
- HOW THIS WILL WORK
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Individual- He/she goes to the doctor, and pays the full doctor bill until he/she reaches his $350 deductible. From this point on when he/she has any type of medical care he/she pays 10% coinsurance of the negotiated rate of the medical bill. Once he/she pays the out of pocket maximum of $1000, now the company pays 100% of the medical claims.
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Family of 2—Husband and wife - Wife has a lot of medical problems and reaches a deductible of $350 first, she will then go to only paying 10% coinsurance of the negotiated rate of the medical bill. The wife continues on and reaches the individual out of pocket maximum of $1000, now the company pays 100% of the medical claims. The husband still has not reached the $350 deductible so is still paying 100% of his doctor visits. He has reached his deductible and is now paying 10% coinsurance, once he reaches the $1000 out of pocket maximum all his medical claims will be paid at 100% by the company like his wife’s.
3. Family of 3—Husband, wife and child-no one in the family as any major medical problems, they all combine reach the $700 family deductible, and move to the 10% coinsurance, since none of them reach the individual out of pocket $1000 they all together reach the $3000 out of pocket maximum together to move to the level were the company will pay 100% of their medical claims. PRESCRIPTION COVERAGE OUT OF POCKET MAXIMUMS There is an Out of Pocket Maximum of $900 Individual and $1,800 Family. These rates are for the life of this contract. Out of Pocket Maximum provisions:
- Only applies to Network prescriptions drug copays
- The amount that is applied to the out of pocket maximum is the network prescription drug copay
- With Family coverage a covered person has satisfied the out of pocket maximum once their copays satisfy the individual out of pocket maximum amount. The family out of pocket maximum is met once any combination of covered person’s prescription drug copays meets the family out of pocket maximum amount. It is not necessary that any one individual reach the individual out of pocket maximum amount, but no one individual may contribute more than the individual out of pocket maximum amount.
PRESCRIPTION COPAYS As of 2011 we will no long be able to get a 60 day prescription, you will only be able to get 30 days or 90 days. Retail in Network Prescriptions copays (up to 30 day supply)
| Generic |
$10 |
| Formulary/Preferred |
$20 |
| Non-Formulary/Non-Preferred |
$40 |
Retail for out of network Mail Order Copays (up to 90 day supply)
| Generic |
$20 |
| Formulary/Preferred |
$40 |
| Non-Formulary/Non-Preferred |
$80 |
In 2011 and 2012 you may use mail order through CVS Caremark or you may pick up your 90 day prescription at any CVS pharmacies for the mail order copay. OTHER CHANGES WITH PRESCRIPTIONS Maintenance prescriptions will be required to go from 30 day supplies to 90 day supplies (mail order) after the second refill at a retail store. Personal Choice Drugs will no longer be covered under the plan the participant will have to pay 100% (example: anti-wrinkle injections, erectile dysfunction agents, hair-growth agents, hair removal agents, topical anti-aging agents and fertility and diet medications. Mandatory Generic-if a generic drug is available and you opt for the brand name equivalent, you will pay the generic copay plus the difference in the cost between the generic drug and the brand name drug you selected. This applies regardless of your reason for not using the generic drug or if your doctor has written dispense as written on the prescription or no substitution. CAREPLUS This is a new option open to the Southeast for the first time during the 2011 open enrollment. This will be a supplemental coverage that will cover specific medical treatments (mostly cancer) that are not covered under you normal health care plans. You will be receiving more information about this plan during the year and at open enrollment so you can make an informed decision about this product. The charge for this coverage is projected to be $1.00 Individual and $2.00 Family. There is some information about this on the web. DISCLAMER-THIS INFORMATION IS CORRECT AT THIS TIME, THERE IS A POSSIBILITY OF SOME CHANGES AS MORE INFORMATION IS KNOWN.
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Last Updated ( Tuesday, 29 June 2010 )
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